Laparoscopic Surgery

Mr. Peter Grossberg

The word laparoscopy is derived from the Greek roots lapara meaning loin or flank and skopien, which is to see, view or examine.

Laparoscopic surgery is commonly accepted as minimally invasive surgery to any part of the abdomen whether intra or extraperitoneal. The term minimally invasive surgery whilst frequently used in abdominal surgery as a substitute for laparoscopic surgery is not strictly accurate as minimally invasive surgery is used in other parts of the body such as the thorax (thoracoscopy) and in joints (arthroscopy)

Laparoscopy has been commonly used by the gynaecologists since the 1960’s for both diagnostic and therapeutic treatment of their patients. Their use of laparoscopy however was limited by the equipment such as the direct viewing laparoscope, the paucity of appropriate instruments and the inability of assistants to give meaningful help without a direct view. The development of the computer chip TV camera attached to the laparoscope in the 1980’s allowed video guided surgery to be performed allowing the assistants to become involved in the operation. Specialised instruments were developed to perform the increasingly more complex and variety of operations. The rapid developments in the 1990’s and the early part of the 2000’s of video technology, including digital imaging, has allowed more detail to be viewed in the operative field and this allows finer and more complex dissection to be performed. The basic equipment for laparoscopy is the Video laparoscope, an insufflator, CO2 and a source of energy for cutting or burning i.e. diathermy, or laser.

There were considerable technical considerations by the surgeons that had to be overcome before laparoscopic surgery became mainstream. The most obvious was transporting a 3D image in open surgery to a 2D view on a screen with the added loss of depth of field and the view was significantly magnified and sometimes distorted. There was also a loss of tactile sensation transmitted to the surgeon’s hands as well as the instruments being in a fixed position thus creating some limitation of movement and the development of a fulcrum for the various movements.

Entering the abdomen initially was via a wide bore needle using the Veress needle, which was a blind puncture, a pneumoperitoneum was then created and the laparoscope was then inserted. Safety with this technique was always a concern for the general surgeons and an open technique was soon developed (Hasson) allowing a safer entry under direct vision before the laparoscope was inserted. The other ports for the instruments were then inserted under direct vision minimizing injury to the intra abdominal organs. This was particularly important in patients who had had a previous operation and may have developed adhesions.

Visualisation in the abdomen require a space whether intra or extraperitoneal and this is created with the insufflation of CO2. This gas is used as it is readily available, is relatively cheap, is soluble, suppresses combustion and causes minimal damage to the organs. The pressure in the abdomen is usually set to 10-14 mm Hg and usually with a flow of 20-40 litres per minute. Higher pressure is used on occasions but prolonged use or prolonged time of operations can lead to cardiac and respiratory problems.

The initial commonly performed laparoscopic procedure was the laparoscopic cholecystectomy and that started the laparoscopic revolution. The initial operations were done on thin relatively healthy young patients and published in the late 1980’s by French and American surgeons. Since the 1990’s it has become the gold standard for the management of cholelithiasis and thus without ever having gone through a surgical trial comparing open and laparoscopic management of gall stones. Whilst initially there were some concerns about the morbidity and mortality of this procedure the results have shown a significant improvement in the management of this disease and a decrease in the morbidity and mortality.

Laparoscopic surgery is now considered a safe procedure in experienced hands and the indications have been extended to patients who are obese, sick, and frail as well as having had previous abdominal procedures. The types of operations that are now performed include cholecystectomy, appendicectomy, diagnostic laparoscopy, colorectal surgery, small bowel resections, surgery for the morbidly obese, and all forms of gynaecological surgery, inguinal hernia and ventral hernia repairs as well as urological surgery. Laparoscopic surgery is also used extensively in trauma.

Recent development with instrumentation has lead to single incision laparoscopic surgery (SILS) and dual incision laparoscopic surgery (DILS) Robotic surgery is laparoscopic surgery by remote control and is a natural extension of his technique but its place in general surgery is yet to be determined.